HomeMy Public PortalAbout5078 SERENO DR_Electrical__ WORKERS COMPENSATION DECLARATION �19�=/117 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm °td°s m that I have a certificate of consent to self 7
insure, or a certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
cr a certified copy t^hyer,eDQf 80
(Sec 30,
Policy `*30a =`'ompony FOR APnICANT TO FILL IN I JOB
❑Certified copy is hereby furnished New Residential Bldgs S Pools J C1'
EACH NO FEE ADDRESS
trfied copy is filed with the county building inspec- 1 8 2 Family Sq Ft L $ — S LOLITY
non d partm nt Multi-family Sq Ft — NEAREST
CRO55 57
Residential Swimming Pools
Date Applicant FIRMN NAME
CER FICATE OF EXEMPTION FRO4 WORKERS Outlets Roc—Light_Sw_ MAIL
COMPENSATION INSURANCE Fust 20 ADDRESS
(This section need not be completed If the work Involved by Total No Additional CITY Tel No
the permit is for one hundred dollars ({100)or less)
certifym RAN CHECK
that the performance of the work for which manner
�_ APPLICANT
permit is issued shall not employ any person in any manner
so as to become subject to the Worker Compensation Laws Lighting Fixtures First 20 ADDRESS
Total No Additional
Date Applicant CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, YOU should become subject to the Workers Range— Heater—DW _ APPLICATION
Compensation provisions of the Labor Cade, you must forth- Oven — Dryer —W M _ ADDRESS
with comply with such provisions or this permit shall be
deemed revoked Hood — Fan —OTel No
ther_ CIN
LICENSED CONTRACTORS DECLARATIONi LICE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Au Cond REG NUMBER Clas
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY Y
and Professions Code,and my license is in full force and effect �� a
Size 8 Type HP, KW KVA or KVAR Q
License Number Lic Clan r Up to 1 Incl FINAL r,Q 0
Connector
Over 1 to 10 Ind DA's �J VALIDATION cc
to Over 10 to 50 Incl F
❑ I am exempt under Sec Over 50 to 100 Inc BY AL l'-
W
B 8P C for this reason Over 100 V a
Dote Services, Swbd , MCC 8 Ponelboards _ Z
0 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 610 V
❑ Exemption for Reg Maint Elect Over 1000 Amp or i Over 600 V
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Temp Power Pole 8 Appurtenances
I hereby affirm that I am exempt from the Contractors License Sign with One Branch Circuit 1 1TEil:,
Law for the following reason (Section 7031 S Business and Additional Sign Branch Circuits
Professions Cade) I TOTAL 122. 85
❑ 1, as owner of the property, will do the work and the Misc Conduits&Conductors CHECK
ly2 p-�
structure is not intended or offered for sale(Section 7044 Other (See Complete`Fee Schedule)_
Business and Professions Code) (HpN6E ,IJIJ
CONSTRUCTION LENDING AGENCY
I hereby off irm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) [II]OIJ-UIQ[I], /j1�5�Y1
(Sec 3097 Civ C )
PLAN CHECKING FEE 7703 1 AI'liu:i1
Lender s Nome '
PERMIT ISSUING FEE
Lender Address pp �?� A
I cerci that I have rood this application and stale that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and ,
hereby thorize representatives of this County to enter upon i
the a mention :,pry y for inspection p---1 a
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of a �'